The following are among the most common conditions patients complain about and a brief explanation of my approach to treating the problem.
1. Forefoot pain: This is a general complaint and can be caused by several different causes.
Some pain located under the forefoot can be the result of a focused callus than can become deeply embedded into the top layer of the skin (the epidermis). Patients feel like they are walking on a pebble or stone. The treatment is to carefully and painlessly remove the collection of hard keratin (callus) thereby relieving the pain. If the condition recurs several times over a short period of time I will recommend a modification of footwear or a modified footbed or foot orthotic to relieve pressure from the painful area.
Some forefoot pain can be located under a specific toe, usually the second toe, and be accompanied by some swelling around the toe and even the forefoot itself. This condition is often the sign of inflammation around the joint connecting the toe to the foot (the metatarsalphangeal joint) and can be described as capsulitis. If the condition is not treated and gets worse it can lead to a tear of the soft tissue around the joint, become very painful and lead to the formation of a hammertoe or even a dislocation of the joint. The treatment is focused on relieving pressure from the joint and may include a cortisone injection or even placing the patient in a walking boot. Patients will need to stop weight bearing exercise that puts a lot of pressure on the forefoot until this condition is healed.
Another common cause of forefoot pain is pain localized to two toes, usually the third and fourth or sometimes the second and third. Patients complain of a burning or tingling or shooting sensation going into the toes. Pain is worse with bending of the toes, like going up or down stairs or wearing a shoe with a high heel and narrow front. Patients may say the pain gets better when they take their shoes off and rub the toes. This condition is usually a sign of a neuroma, or, a pinched nerve between the toes, commonly referred to as a Morton neuroma. This is treated by changing footwear to wider shoes and can also include the use of felt pads in the shoe or on the foot itself and sometimes a cortisone injection. Other treatments are available as well including a series of alcohol based injections.
2.Pain in the heel area of the foot is one of the most common foot problems. The source of the pain is inflammation of the ligament that helps support the arch of the foot. This ligament is called the ‘fascia’ and when it is inflamed, we call the condition, ‘fasciitis’.
Plantar fasciitis can occur suddenly and cause debilitating pain. Patient’s usually describe having pain in the heel of their foot when they first get out of bed or stand up after sitting. The pain usually subsides as one walks around only to recur the next time one stands up after sitting or sleeping. If not treated promptly, this condition can rapidly deteriorate and cause daily limping on the painful heel.
Treatments include the application of an athletic taping to help support the inflamed ligament and the use of a pre-fabricated arch support to begin giving you immediate relief. In some cases I recommend a cortisone injection, although we use them sparingly. The doctor may prescribe an anti-inflammatory medication and will instruct you in appropriate stretching exercises which are very important for healing. In some case, Dr. Friedman will recommend a custom made foot orthotic made from a mold or cast of your foot. Most patients experience a decrease in symptoms after our in-office treatment together with following the instructions we provide for exercises to be done by you at home. Dr. Friedman recommends against surgery or other invasive treatment for this condition.
3. Plantar warts
Warts on the bottom of the feet are common especially in children and can be very painful.
Warts are caused by a human papilloma virus that spreads through direct contact usually when the skin is wet or moist and when there is some type of crack or split in the skin. Therefore it is important to dry your feet well after showering or swimming and especially after sports when the feet become sweaty.
Warts create a hard covering of callus material making patients feel like they are walking on a rock or pebble stuck into their foot. The doctor will be able to determine if the pain is caused by a wart of only a callus.
Many different treatments exist for warts. Suffern Podiatry uses conservative treatments with very good results. Recently we started using a needling procedure which despite its name is not painful. The technique irritates the surface of the wart along with a topical medication and stimulates the body’s own immune system to fight the wart. We see the warts responding to the treatment after the first treatment although it may take two or three visits overall. Our success rates have been high. Our office does not believe in surgically cutting the warts out or using any other invasive treatments.
4. Ingrown toenails
Ingrown nails are very painful and they are painful even if they are not infected.
If the ingrown area is just near the corner of the nail, that painful area can often be trimmed back quite painlessly. Sometimes the toe needs to be anesthetized with an injection. Our office uses one of the smallest size needles to make the injection as painless as possible. If the toe was infected the doctor will prescribe an oral antibiotic.
If this problem continues to recur, Dr. Friedman will recommend an ‘ingrown nail correction’ which removes the ingrown portion and treats the nail matrix (the cells from where the nail grows) with a chemical so it will not grow back. The success rate is well over 90%.
How To Cut Your Toenails
Toenails do not need to be short. Some of the white portion at the edge of the nail should be visible. In addition it is important that the corners of the nail are also visible. If they become buried in the skin of the nail folds on either side of the nail, the nail will most likely grow ingrown. I generally recommend trimming the nails when they become bothersome or otherwise uncomfortable, and trim them just enough to still leave some of the white portion of the nail edge and to leave the corners of the nail visible.
The patient with a gout attack wakes up to a throbbing pain in their toe or otherwise has a sudden onset of pain for no apparent reason. Gout is an inflammation of a joint, often the big toe, caused by an excess of uric acid in the blood. Gout is estimated to affect about 2% of the population and occurs in men and women.
Treatment for a painful gout attack generally includes the drug colchicine (Colcrys or Mitigare ) together with a non-sterioidal anti-inflammatory. Even with medications the pain and swelling may take a couple of weeks to fully resolve. Patients should also stop eating foods which increase uric acid levels and switch to a dairy diet including whole grains. Coffee has been reported to lower uric acid levels and some people maintain that drinking black cherry juice helps reduce the pain of a gout attack. A steroid injection around the affected joint can provide quick relief, if needed.
Conditions besides gout can also cause a joint to be swollen and painful. Making a definitive diagnosis is important as the treatment for other conditions, such as an infection and abscess in the joint is markedly different. A blood test of uric acid levels can be helpful, but not during an attack when the levels may be falsely low.
6. Cold Toes
Winter is the prime season for seeing patients with complaints of very cold toes but some people experience this problem in the fall as well. This condition is called Raynauds and is caused by contraction of the small blood vessels in the toes and sometime fingers as well.
When temperatures begin to fall it is important to insulate your torso, from neck to waist, in warm layers and use thermal long underwear as well. Wear wool or otherwise extra warm socks over a thin sock liner. And, wear warm boots as well. There are some treatments to address the pain associated with this condition and treatment is often needed to help heal sores that occur as a result of the poor circulation.
Patients often complaint of a burning tingling sensation on the bottom of the feet or involving the toes. This is often the sign of peripheral neuropathy, or damage to the nerve endings in the feet and toes. One of the most common reasons is diabetes but there are other causes as well. The doctor will try and understand the cause of the neuropathy and will discuss treatment options for painful neuropathy sensations. In addition, people with loss of feeling in their feet often develop foot wounds. Dr. Friedman will work to heal the wounds and create strategies to try and prevent the wounds from re-occuring.
8. Fungus toenails
Discolored, thick, yellow, unsightly and painful toenails is an extremely common foot problem. The fungus that causes toe nail infections also causes athlete’s feet as well as “ringworm” and “jock itch”.
Since the infection is actually under the toe nail, topical treatments are usually ineffective or minimally effective. The most effective treatment continues to be oral medication which can kill the fungus organisms even under the toenail. I prescribe an oral medication, terbinafine (Lamisil) but use a pulsed dose method. This means that I have my patients take the medication for a short period of time than repeat the dose may weeks later. The results of this treatment are good and I am able to reduce how much medication my patients have to take. I use this treatment for teenagers and adults when appropriate. Debridement of the nails, thinning and shortening them, also remains an important management tool for this condition as well. (Laser treatments have not yet been shown to be so effective nor have any of the many over the counter remedies either).
9. Bunions and hammertoes
9. Bunion and hammertoe deformities can be painful and interfere with patients’ ability to wear the footwear they want to wear. When bunions and hammertoes interfere with a patient’s activities of daily living it could be time to consider surgical correction.
Bunion surgery involves cutting and resetting bone called the metatarsal and maintaining that position with a bone screw. This procedure reduces or eliminates the ‘bump’ and helps the great toe remain straight. Healing requires about six weeks. During that time patients can usually walk in a special surgical shoe. Swelling of the foot after surgery however, can sometimes take a few months to resolve. Hammertoe repair involves removing a section of the toe bone to straighten the toe. The toe may need to be held in place with a metal pin. Most patients can get back into a soft shoe, such as a sneaker within 4-6 weeks after bunion surgery and sooner after hammertoe surgery. Returning to wear dress shoes may require several months. Dr. Friedman will counsel you about your surgical options and make an appropriate referral.
10. Gait concerns in new walkers
Parents of toddlers who have recently started walking will ask the doctor to evaluate their child’s walk concerned that the child may be walking in-toed or out-toed or have flat feet. Dr. Friedman has many years experience evaluating new walkers and usually can allay a parent’s concerns. If there is a need for intervention the doctor can prescribe a brace or arch support if indicated.
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